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NPI Code Detail

MEDICARE: KRYSTAL PEA

MEDICARE: KRYSTAL PEA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor
2171M00000XCase Manager/Care Coordinator
3101YP2500XProfessional Counselor5809LA

General Provider Information

NPI Number : 1790158400
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRYSTAL PEA
Provider Business Mailing Address
First Line : 4023 ESPLANADE AVE
Second Line :
City : SHREVEPORT
State : LA
Zip : 71109-5036
Country : US
Telephone Number : 318-572-7418
Fax Number :
Provider Business Practice Location Address
First Line : 2219 CLAIBORNE AVE
Second Line :
City : SHREVEPORT
State : LA
Zip : 71103-4301
Country : US
Telephone Number : 318-779-0434
Fax Number : 318-210-0000
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/03/2015
Last Update Date : 05/13/2019

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Directions to “ KRYSTAL PEA ” Practice Location

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